DESCRIPTION: According to the model of person-environment fit (P-E fit), older adults are at risk for poor outcomes when the demands and resources available in the environment are no longer in balance with the individual's everyday competence (the ability to solve problems associated with everyday life). It has been estimated that 29% of Community Living Center (CLC; VA nursing homes) residents may not require nursing home levels of care and could safely reside in the community with appropriate rehabilitative services. In VA, a major focus is to minimize time in CLCs by providing rehabilitation and transitioning Veterans to the community. CLC staff and Veterans face barriers to facilitating these transitions (e.g., caregiving needs, housing, etc.). N standardized process exists to assure that treatment planning includes processes to maximize P-E fit. The objective of this study is to develop a toolkit the CLC interdisciplinary team can use to 1) assess the Veteran's everyday competence; 2) develop personally meaningful rehabilitation goals based on everyday competence; and 3) conduct structured treatment planning to support resident goals around transitions back into the community. Acknowledging that even the most effective intervention is worthless if no one actually uses it, we propose a three-phase research process: Understand Develop Trial. Phase 1 (Understand) focuses on gaining an understanding of the current environment, discharge planning processes, and outcomes in CLCs. In Aim 1a, we will use administrative data to examine outcomes and predictors of successful/unsuccessful transitions among CLC residents. Aim 1b employs qualitative interviews, to understand the current barriers and facilitators to transitioning CLC residents, identify everyday scenarios residents face, and collect staff suggestions for appropriate goal-setting domains. For Aim 1c, we will use field observation to understand the workflow, relationships, and interactions between members of the interdisciplinary team during transition planning. Phase 2 (Develop) will use information gathered in Phase 1 to develop the Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit components, including rehabilitation goal-setting domains and creation of a structured manual to guide the CLC interdisciplinary team through the assessment, goal-setting, and treatment planning steps. Phase 3 (Trial) will be a quasi-experimental effectiveness trial of the ECAP-CT toolkit in the Houston (n=30 residents) and Tuscaloosa (n=30 residents) VA CLCs. The toolkit will be implemented sequentially in the two sites allowing for adaptation. Our primary outcome is transition outcome (successful/not successful), which will be compared to concurrent administrative data gathered from two matched comparison sites (n=60). We will conduct an exploratory cost-effectiveness analysis of the toolkit compared to usual care within the context of this trial. The PI's overall career aim is to become an independent rehabilitation researcher with expertise in developing and testing interventions targeting the needs of CLC residents, maximizing autonomy, independence, and function. Long-term, her career goals include developing strategies for assessment of everyday competence among CLC residents, setting resident-directed goals, and developing care plans to transition Veterans back into the community. The CDA-2 mentoring team includes established VA researchers with expertise in vulnerable older adults, assessing everyday competence, intervention development and evaluation, and long- term care transitions. With the guidance of the mentoring team, areas that would benefit from additional training have been identified The training aims outlined in this CDA-2 award will provide additional experience in these areas: 1) evaluation of patient-centered interventions, including cost-effectiveness and psychometrics methodology; 2) intervention development; 3) experience and knowledge of VA rehabilitation services; and 4) submission of a RR&D Merit Review Award. These objectives will be achieved through mentoring and attending seminars, formal courses, and conferences.